TRIAGE

(Disaster Triage Situation)

Triage is the screening or classification of sick, wounded, or injured persons during war
or disaster, to determine the priority needs for efficient use of manpower, equipment
and facilities.

It’s the process by which patients classified according to the type and urgency of their
conditions to get the: RIGHT PATIENT, to the RIGHT PLACE, at the RIGHT TIME, with
the RIGHT CARE PROVIDER

DISASTER TRIAGE

 a disaster by definition overwhelms response capabilities, a mass casualty

incident (MCI) occurs more commonly and is defined as a situation that places a
significant demand on medical resources and personnel
 there are large number of patients requiring triage, Regardless of whether a
situation is classified as a medical disaster or MCI, it requires rapid and effective
triage methods.

Principles of successful disaster triage

 Never move a casualty backward (against the flow)

 Never hold a critical patient for further care.
 Salvage life over limb
 Triage providers do not stop to treat patients
 Never move patients before triage except in cases of:
– Risks due to bad weather
– Impending darkness or darkness has fallen
– A continued risk of injury
– Medical facilities are immediately available
– A tactical situation that dictates movement

Benefits of Triage

There are three major reasons why triage is beneficial in the disaster response:

1. Separates out those who need rapid medical care to save life or limb.
2. By separating out the minor injuries, it reduces the urgent burden on medical
facilities and organizations. On average, only 10-15% of disaster casualties are
serious enough to require over-night hospitalization.
3. By providing for the equitable and rational distribution of casualties among the
available hospitals, triage reduces the burden on each to a manageable level,
often even to "non-disaster" levels.
Disaster Triage
– Increased no. of victims
– Limited medical resources
– Long scene times
– Frequent reassessment
– Compartmentalized victim treatment
– Multiple victims
– Trauma
– Medical
– Austere conditions

Triage Precautions

 Avoid hazardous materials

 Avoid unsafe situations
 Wear personal protective equipment

Basic Principles

 Initial patient assessment and treatment should take less than 30 seconds for
each patient
 Patients are triaged based upon 4 factors

– Ability to walk away from the scene

– Respiration: > or < 30 respirations per minute
– Pulse: Radial pulse present or capillary refill < or > 2 seconds
– Mental Status: able/unable to follow simple commands

 Respirations Pulse Mental Status

Stages of Disaster Triage

Immediate

 Local providers
 Follows pre-hospital model
 S. T. A. R. T. (Simple Triage and Rapid Treatment)

Secondary

 Disaster medical responders

 S. A. V. E. (Secondary Assessment of Victims Endpoint)

S.T.A.R.T Triage

 Rapid approach to triaging large numbers of casualties

  Easy to remember
 Designed to be performed by first responders (paramedics)
 One of several triage programs available
 Most common protocol used for triage
 Assumes personnel under a great deal of:
– Stress
– Limited number of rescuers to rapidly triage a large number of patients
 Patients systematically moved to treatment areas for more detailed assessment,
treatment & transport
 Triage victims in less than 30 seconds
 Aim: Rapidly find Immediate patients

S.T.A.R.T. TRIAGE

RESPIRATIONS

 None - Open the Airway

 Still None? – DECEASED
 Restored? - IMMEDIATE
 Present?
 Above 30 - IMMEDIATE
 Below 30 - CHECK PERFUSION

PERFUSION

 Radial Pulse Absent or

Capillary Refill > 2 secs = IMMEDIATE

 Radial Pulse Present or

Capillary Refill < 2 secs = CHECK MENTAL STATUS

MENTAL STATUS

 Can Not Follow Simple Commands (Unconscious or Altered LOC) = IMMEDIATE

 Can Follow Simple Commands = DELAYED

***If patient is tagged immediate upon initial assessment, only attempt to correct airway
blockage or uncontrolled bleeding before moving on to next patient.

NO MORE THAN 30 SECONDS PER PATIENT!

TRIAGE TAG

 Standardized
 Basic information
 Color coded
 Means of attachment
 Tear-off sections for tracking
 Need to apply new tag when re-triaging

DISASTER TRIAGE COLOR TAGS

There are four colors, and a wounded individual will be tagged one color based on their
health status. The four colors include:
 Red
 Yellow
 Green
 Black

Red Tag: IMMEDIATE

 when a patient is tagged red, STOP and get them treatment because they have
first priority in receiving care.

 1st priority: Altered RPM

 Injuries are life-threatening but they could possibly survive if they are immediately
treated.

 Severe alteration in breathing, circulation, and neuro/mental status

 Conditions that would cause a wounded individual to be tagged red (think of

conditions or systems of the body that if severely damaged could majorly alter the
breathing, circulation, and neuro system)

 Spinal cord injuries: remember various areas of the spinal cord control breathing,
brain and heart function, shock can occur like neurogenic, cardiogenic etc.

 Severe bleeding (internal or external): if the patient is treated immediately so the

bleeding could be stopped and transfused with blood products they may live

 Major burns that affect a high percentage of the body: burns can affect the
circulation and the respiratory system (depending on the burn type and where it’s
located)

 Some types of major respiratory trauma: pneumothorax etc.

Yellow Tag: DELAYED

 slow down or delay because you’re about to stop. Therefore, when a patient is
tagged yellow their treatment is delayed but for only about an hour or so because
they could turn critical based on their presenting injuries.

 2nd priority: majority of victims, RPM normal

 Significant injuries BUT at this point their breathing, circulation, and mental status
is within normal range but this could change.

 Conditions:

 Bone fractures: major fractures that require medical treatment

 Integumentary damages: open wounds, deep lacerations etc.

Green Tag: MINOR

 these wounded individuals are termed the “walking wounded”. Therefore, these
patients can get up and GO (move around). Their injuries are minimal.

 3rd priority, may be tagged later

 Treatment can be delayed for several hours, and some can treat themselves.

 Breathing, circulation, mental status not expected to change

Black Tag: EXPECTANT

 Wounded is dying or expired.

 Injuries are deadly to the point the individual will not survive.

 Absence of breathing, circulation, mental status.

 Mortal wounds

 Die despite medical attention

 Dead when initially assessed

Arrival at the Scene…

As incident commander or first responder, the first action is to assure that the scene
does not present any health or safety risks for your team.

SAFETY COMES FIRST!

S. T. A. R. T. Procedure

 Begin where you stand

 Move from starting point in a systematic manner
 Stop at each victim and quickly assess RPM
 Maximum time 1 minute per victim
 Correct life-threatening airway problems
 Tag patient
 Move on!

S.T.A.R.T. ALGORITHM
TRIAGE PRIORITIES

 Your initial goal during triage is to find IMMEDIATE patients. You want to “find the
red and get it out”.

 Your efforts should focus on locating all IMMEDIATE patients, getting them
treated and transporting them as soon as possible.

 Once IMMEDIATE patients have been treated and transported, reassess all
DELAYED patients and upgrade any to “IMMEDIATE-by-mechanism,” depending
on their injury, age, medical history, etc.

When things get hectic with multiple patients rev up your RPM’s.

R - Respiration - 30
P - Perfusion - 2
M - Mental status - CAN DO

Mnemonic: 30 – 2 – CAN DO

JUMPSTART TRIAGE

 System for triaging pediatric patients is called JUMPSTART

 Is used for age range 1 to 8 years

 Has similar algorithm to START system

 The primary differences in this method are the respiratory effort and use of
AVPU.

 Remember, cardiac arrest in children is most often caused by respiratory

complications
LEVEL OF CONSCIOUSNESS

 AVPU
Alert - Awake and alert and needs no stimulus to respond to the environment
Verbal - Requires a verbal stimulus to elicit a response
Pain - Requires a painful stimulus to evoke a response
Unresponsive - Unresponsive to applied stimulus

 ACDU
Alert - Awake and alert and needs no stimulus to respond to the environment
Confused - Does not respond quickly with information about their name,
location, and the time (disoriented)
Drowsy - Sleepy and responds to stimuli only with incoherent mumbles or
disorganized movements
Unresponsive - Unresponsive to applied stimulus

 Simplified Motor Score (SMS)

– Obeys Command – 2
– Localizes Pain – 1
– Withdraws to pain or worse - 1

JUMPSTART ALGORITHM
Transition Phase
 After S. T. A. R. T. completed
 Move victims to secondary triage based on tagging
 Resource dependent
 Safe secondary area available
 May involve just grouping patients together at scene
 Provide stabilizing care
 Re-triage if condition changes (SAVE)

Treatment Unit
 Determine location for treatment area
 Coordinate with the Triage unit to move patients from the triage area to treatment
areas
 Establish communication with Incident Command
 Reassess patients, conduct secondary triage to match patient with resources
 Direct movement to ambulance loading area

Staging Area
 Location designated to collect available resources near incident area
 Several staging areas may be required
 Should be easy for arriving resources to locate
 Staging area may need to be relocated as the situation dictates

S. A. V. E.

 Secondary Assessment of Victim Endpoint

 Benson, Koenig, and Schultz – Pre-hospital and Disaster Medicine, 11(2), 1996
 Apply limited resources to gain most good
 Designed for catastrophic disasters
 Provide immediate on-scene care but transport significantly delayed (days)

S. A. V. E. Assumptions
 Local providers have triaged victims (S. T. A. R. T.)
 Previously trained local providers
 Limited medical and transport resources
 Prolonged evacuation to definitive care
 Patients may deteriorate because of transport delay

S. A. V. E. Categories
 Those who will die regardless of care
 Those who will survive whether or not they receive care
 Those who will benefit from limited immediate field intervention
 These will receive more than basic care and comfort measures
S. A. V. E. Procedure
 Reassess patient based on S. T. A. R. T. triage
 Assign patients to areas
 Observation
 Those that will die
 Periodic reassessment for improvement
 Those not needing care
 Provide basic care
 Periodic reassessment
 Treatment area
 Treated in order of severity and resources

S.A.V.E. Triage Areas of Assessment

 Vital Signs
 Airway
 Chest
 Abdomen
 Pelvis
 Spine
 Extremities
 Skin
 Neurologic Status
 Mental Status

S.A.V.E. Triage Categories

 RED: require immediate intervention

 YELLOW: require intervention but can tolerate a brief delay
 GREEN: do not require intervention to prevent loss of life or limb
 BLACK: dead or unsalvageable

S.A.V.E. Treatment

 Patients triaged to treatment area are treated in priority according to severity,

resources, and time.

 If patient does not respond to treatment, re-tag and send to observation area.

 Patients who would benefit most from early transport should be so designated in
the event transport becomes available.
Transportation Unit

 Management of patient movement from the scene to the receiving Hospitals

 Works with Treatment unit to establish adequately sized, easily identifiable patient
loading area
 Designates an ambulance staging area
 Maintain communication with Incident Command

***********

 Triage only suggest a transport order

 Mass Casualty is really a BLS skill
 Be creative
 No ambulances?
 Reassess Delayed patients as soon as possible and upgrade to Immediate if
necessary (Serious MOI / Age/ HX).